500 S. Anaheim Hills Rd. 238
TYP!: OF P!:RMIT
Tenant Improvement (Limited)
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BUILDING DIVISION
200 S. ANAH!:IM BLVD.
(714) 765 - 5153
INSP!:CTlON R!:QU!:ST UN!::
(714) 765" 4626
C!:NSUS.CODE: .437
QUARTER SECTION: 192
. BUILDING PERMIT NO. BLD2004-02696
DATE: 8/11/2004
JOB ADDRESS: 500 S ANAHEIM HILLS RD 238
L!:GAL DESCRIPTION: T 4 R 9 SEC 12 POR OF SEC
CONTRACTOR INFORMIT10N:
INTEGRITY CEILING SYI;TEMS
1220 PIONEER #B
BREA, CA. 92821 0000 ,
BUSINESS PHONE: 71452"-7491
JOB DESC~IPTION:renant improvement, 2nd floor m~dical suite remo,del (r'1~lical office bldg)
VALUATION:' 20,000.00 . 1,"
I OWNER-BUILDE'itOECLARATION
t hereby affirm under:. penalty of perjury that I am exempt from the Contractocj",'ucense_Law for the following reason (Sec, 7031,5 Business and
Professions Code: any dty or county which requires a pe:rmit to construct, ;JJt~(, improve; demolish or repair any structure, prior to its issuarice,also
requires the applicant for such permit to ,file a signed statement that he i$lk:~hxd purslJant to the provisions of tne Contractor's License Law (Chapter
-9)(commencing with S.ecticr. 7000 of DivisiqlJ 3'of:t.he Business and Profess~+ls.c,9de)',oi'that he is exempt'therefrom and the ba~isforthe alleged
exemption. Anyvk,l<:ltJofl of Section 7031.5 by any ClppJicant for a permit stlb!e-ct's'ihe: a'ppJicant to a civil penalty of not mor~than five hundred dol\.~rs
($500).' . . ! . '. . ;
U' ;, as owner at property, or my employees with wages as their sole c()mp~~nsatj"{,n, will dQ,the work, and thestj'ucture is flot intended or. offered_f6r
sale (Sec. 7044 Business and Plofessions Cod~:Jhe Contractor's.U(f~ns€-l':;:;VJ oj~~s root apply to an ownecof pro~erty who builds or improves
therE'on, and who does such worl< himself or herse~f or through hts cr lier OW~I.all1~:)yees. pr~vided that.~ch im1?,!pvernems are not, intended or :~
offered for sale. If, however, thE.' building or improvement is sold with one y(o~~r of completion,.the owner~builder,wUI have the burden of provl!1gthat,he
did !'lotbu~d or improve ttJr the purpose of sale). . 'j . '
. n I, as the owner of the property, am exdusively"contracting with Ijcens~d ~or:tr3ctors to construct th.eproject (See. _7044 Busi.nessand Profession's
Code: The Contractor's License Law does not apply to an owner of proper.:\.-t1ho b'-.lnds or itnproves thereon, 'and who contract::; for sU?1:,projeds with
ljontraetor(s) licensed pursuant to the Contractor'g-Ucense Law).. .
I am exempt under Sec.. ,8 & P,C. ~ortl1[s reason: ...._J_
Date:' Owner: f
! WORKER'S COMPENSATION DECLARATION 1--
I hereby affirm under penalty of perjury one o~ the following declarations: . \ '
o . I have and will maintain ,8 certificate of mnsent t? se.lf-insure for wOrke(~compensation.
~ideq for by Section 3700 of the Labor.Code, for the performance of ~h~.\'.Jork for which
thi permit is issued. -. .._ . .~
~ I have and will maintain worker's'compensation i'1surance,as required L~v-8ection 3700 of
the labor Code. for the performance of the work for whiCh this permit is i"SsU~::! ,Myworker's
Compensation in sura nee carrier and policy are: .,. '1
Carrier: STATE COMPENSATION FUND . Policy Number. 4610980;03
This section need not be compl.eted if the pennit is for one hundred dollars ($1D~;1-.jr less.
. 01 certify.that in~he perfonnance of the work for which thIs permit is issu~tL! ~hall not .
employ any person in any manner so as to become subject to the workers c':[n,_pensat!on laws
ofCallfomia, and agree that if I should become subject to th 0 r's co 1p.;~ris-ati9n
provisions of Section 3700 of the-labor Cod f h plyw. ..))s~provisions:
. APPLICANT: ED LACIVITA
OWNER INFORMATION:
Ctf-3 Hills Llc
4001 Macarthur Blvd
New port Beach, CA 92660
ARCHITECT/ENGINEER INFORMATION:
PROCESSED \3Y: FAN
J L LICENSED CONT.MCTORS DECLARATION I
I hereby affirm u<1der penalty -of. perjury that.1 tl';Tl
licensed under provisions ofc.ha ter 9 (com encing
with Section 7000) of Diw.::ion. ft Busi 5S nd
Professions Cod
8/11/2004
Date:
Con tractor
NUMBER
..700357 .
TYPE
:TYPE
EXPIRATION DATE'
10/31/2004
B
99
Date: 8/11/2004' Applicant
WARNING: FAILURE TO SECURE WORKER'S COMPENSATION COVEf~M;E IS.
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENAr-r1ES AND CIVIL
FINES UP TO ONE HUNDRED lrlOUSAND DOLLARS ($100,000), IN AOD!.TION TO THE
COST OF COMPENSATION, DAMAGES AS PROViDED FOR IN SECTION\3706 OF THE .'.
LABOR CODE, INTEREST AND ATTORNEY'S FEES. ~ .
I CONSTRUCTION LENDING AGENCY __
I hereby affirm under p~nalty of perjury that _there"is aconstru9\ion"lending a~l.?n'?Yof()f.;!!1~~ _~;:o-:..:,!::,,>:
--~. ru..,Ia"....~:fvft:lbT-M;.Ii\- iVi u1Wr iiii5-P-t.<1"I,;n;;-isSJ'eti (3ec:'"3iJ'ffl.Gtv:Cr-----<d.4 --.---",-,. _.'
lender's Information:
Construcion Types;
V1HR, , .
Occupancy Groups:
B, , , ,
Fire Sprlnkrere~?
YES
,.',
nd state that the above information is correct. I
Date: 8/1112004
Fees,paid for Permit:
Total:
621.53
Signature of Applicant or Agent
The permit shall eXpire by limitation and become null and void if the. building or
work has not passed final insp~ion 365 days from the date of permit issuance. A'
new permit is required to commence or continue work.
INSPECTION RECORD
INSPECTION . . : INSPECTOR
DATE
Temporary !'ower Pole . ..
Plumbing (DrainlWaste Pipe)
Electrical Ground Electrode/lifer
SetbacklFormsfTrenches (Footings)
Do not install sub floor or pour floor slab until the .
following applicable items have been signed:
plumbing (Water Plpe.sprinkler Valves)
. Mechanical (Groundwork) .'
Electrical (Underground Conduit) '.
Pre.-slab (Compaction/Membrane.Reinf. .
Underpinning' (Floor Joist/Girders)
Do riot cover or conceal the work below until the
following applicable items have been signed: .
1 st Floor Shear . '. .
Firesprinkler (Rough)
2nd Floor Shear . . .
Roof (Sh&athing/DiaphragmlFral1le) . I . '.
MlISonry (ReinfJBond' Beam/Pre-Grout) . ,
Rough Plumbing (Top Out) .
Rough Mechanical . .' .
KOugn 8ectrlCalluryWah) . ~ .)o"T -
Rough Electrical . /"
Framing (Only .fierPlbg.. Elec.. Mech. and Fire)" f112#D'I /
Insulation (SoundlEllergy) . .j'
Do not tape or plaster until the following applicable
items have beep si9l1ed: .. . .
Drywall . . .
Penetrations (Fire Rated) Electrical
Penetrations (Fire Rated) Mechanical
Penetrations (Fire Rated) Plumbing
Inierior Lath. . , . .
Exterior Lath . .
GENERAL ITEMS
Exterior Plaster (Brown Coat)
T -Bar Electrical . .
T -Bar Mechanical . .
T-Bar Structural
Sewer. . . . .
Water Engineering Backflow . .
Water Service . .
FINAL INSPECTIONS .. Date. . Inspector
.
Electrical Final .
Plumbing Final . ,
Mechanical'Final . .
Gas Test
Engineering/Grading Final 765-5126
Fire Dept. Final 765:4040 . . . .
Water Engineering 765.5268 ."
Sub list/Business License 7115-519. . . . .
Zoning 765-5139 . . '.'
Building Final *.st Inspection. Only
tter'Above Complete) '.
PARTIAlIN~PECTIONS
Buildina Inspections
. Mechanical Inspecticlns
Phimbina Inspections
Electrical Inspections'
nr-nr.r,'T EVPI'K'FO' .
tJt.I\NI.1 . 1\.".,. .
INSPECT~ON .
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